Other rules for paying benefits

Are there any other rules I need to know about?

Yes, here are some of the other important rules for you to be aware of – refer to the Fund Rules for a complete list of benefit exclusions.

We only pay benefits for items and services delivered by Medibank-recognised providers.

Restrictions may apply to the number of services you can claim in a particular period.

Some appliances may need to be ordered by a medical practitioner before benefits are payable e.g. nebulisers.

To claim for a CPAP machine or similar device approved by Medibank, firstly, you'll need to hold an appropriate level of hospital cover (refer to your cover summary) for at least 12 months. You'll also need to undergo an overnight investigation for sleep apnoea (sleep study) which is listed in the Medicare Benefits Schedule. Lastly, the device must be purchased or hired within the 12 months following the investigation.

Limitations apply to some benefits. For example, for an initial consultation for an extras service, we generally pay the higher benefit only once per person, per provider per calendar year (if any) for each course of treatment.

Limited hospital benefits apply to podiatric surgery (performed by a registered podiatrist) and dental procedures and you can incur significant out of pocket expenses. 

If you no longer need acute care and stay in hospital for more than 35 days, you'll be classified as a nursing home type patient. If this happens, we'll only pay a small portion of the daily hospital charges and you may need to pay the rest of the cost of your care. If you're in a private hospital, these costs may be substantial. Your doctor and hospital will be aware of this rule which applies to all health funds and they can advise you.

We don't pay benefits for services or treatments where you are, or may be, entitled to compensation and/or damages. For example State Government workers' compensation schemes, traffic accident schemes or public liability claims.

We don't generally pay benefits for hospital procedures not recognised for Medicare benefit purposes (such as cosmetic surgery for non-medical purposes).

To claim for private room priority under selected hospital covers, you'll need to make sure you request a private room at least 24 hours before your stay as well as provide supporting documentation from the hospital about your request. Private Room Priority won't apply to:

  • same day admissions
  • admissions for sleep studies
  • nursing home type patients
  • where your doctor considers that you should be located in a shared room for clinical reasons

No Medibank benefit is payable under extras where there is an entitlement to a Medicare benefit (e.g. allied health services).

It's important you call us on 1300 531 726 for information on recognised providers and the benefits you're entitled to before commencing treatment. 

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